Hypothalamo-pituitary-adrenal axis dysfunction as a contributory factor to chronic pain and depression

The association between emotional abuse in childhood and healthcare utilization in adulthood among sami and non-sami: the SAMINOR 2 questionnaire survey

BACKGROUND

Emotional abuse in childhood is the most common type of childhood abuse worldwide and is associated with a variety of somatic and mental health issues. However, globally and in indigenous contexts, research on the associations between emotional abuse in childhood and somatic and mental specialist healthcare utilization in adulthood is sparse.

AIM

The main aim of this study was to investigate the association between emotional abuse in childhood and somatic and mental specialist healthcare utilization in adulthood in Sami and non-Sami populations, and to examine whether this association differs between the two ethnic groups.

METHOD

This study used cross-sectional data from the SAMINOR 2 Questionnaire Survey - a population-based study on health and living conditions in areas with Sami and non-Sami populations in Middle and Northern Norway. In total, 11 600 individuals participated in SAMINOR 2. Logistic regression was used to present the association between emotional abuse in childhood and somatic and mental specialist healthcare utilization.

RESULTS

Emotional abuse in childhood was significantly associated with somatic specialist healthcare utilization in adulthood (fully adjusted odds ratio [OR] 1.31, 95% confidence interval [CI] 1.15-1.49), with no differences observed between ethnic groups. Emotional abuse in childhood was also associated with mental specialist healthcare utilization (fully adjusted OR 3.99, 95% CI 3.09-5.14), however this association was weaker among Sami (crude OR 2.38, 95% CI 1.37-4.13) compared with non-Sami (crude OR 5.40, 95% Cl 4.07-7.15) participants.

CONCLUSIONS

Emotional abuse in childhood is associated with somatic and mental specialist healthcare utilization in adulthood, with a stronger association to mental healthcare utilization. The association between emotional abuse in childhood and mental specialist healthcare utilization was weaker among Sami than non-Sami participants. Future studies should investigate the reason for this ethnic difference. Our results highlight the need to strengthen efforts to prevent childhood abuse and develop strategies to reduce its societal and personal burden.

Effectiveness of osteopathic manipulative applications on hypothalamic-pituitary-adrenal (HPA) axis in youth with major depressive disorder: a randomized double-blind, placebo-controlled trial

CONTEXT

Osteopathic treatments regulate the neurovegetative system through joint mobilizations and manipulations, and myofascial and craniosacral techniques. Despite the growing body of research, the precise impact of osteopathic medicine on the autonomic nervous system (ANS) is not yet fully elucidated. As to Kuchera's techniques, the stimulation of the sympathetic trunk and prevertebral ganglia contributed to harmonization of the sympathetic activity. However, potential relationships between the harmonization of the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal (HPA) axis largely remain uncertain and warrant further exploration.

OBJECTIVES

This study was designed to evaluate the effectiveness of the osteopathic sympathetic harmonization (OSH) on the SNS and the HPA axis in youth with major depressive disorder (MDD).

METHODS

The study included 39 youths aged 15-21 years and diagnosed with MDD. The participants were randomly assigned into either the OSH or the placebo group. Stimulation was performed on the sympathetic truncus and prevertebral ganglia in the OSH group. The stimulation of the placebo group was performed with a lighter touch and a shorter duration in similar areas. Each participant completed the Beck Depression Inventory (BDI) and the State and Trait Anxiety Inventory (SAI and TAI) before the application. Blood pressure (BP) and pulse measurements were made, and saliva samples were taken before, immediately after, and 20 min after application.

RESULTS

The baseline BDI (p=0.617) and TAI (p=0.322) scores were similar in both groups. Although the SAI scores decreased in both groups postintervention, no statistically significant difference was found between the two groups. Subjects who received OSH had a decrease in α-amylase level (p=0.028) and an increase in cortisol level (p=0.009) 20 min after the procedure.

CONCLUSIONS

Following OSH application in depressed youth, SNS activity may decrease, whereas HPA axis activity may increase. Future studies may examine the therapeutic efficacy of repeated OSH applications in depressed individuals.

Development and Validation of a Treatment Algorithm for Osteoarthritis Pain Management in Patients With End-Stage Kidney Disease Undergoing Hemodialysis

Background

Although osteoarthritis is common in the hemodialysis population and leads to poor health outcomes, pain management is challenged by the absence of clinical guidance. A treatment algorithm was developed and validated to aid hemodialysis clinicians in managing osteoarthritis pain.

Objective

The objective was to develop and validate a treatment algorithm for managing osteoarthritis pain in patients undergoing hemodialysis.

Design

A validation study was conducted based on Lynn's method for content validation.

Setting

To develop and validate a treatment algorithm, interviews were conducted virtually by the primary researcher with clinicians from various institutions across the Greater Toronto and Hamilton Area in Ontario.

Patients

The treatment algorithm was developed and validated for the management of osteoarthritis pain in patients on hemodialysis. Patients were not involved in the development or validation of the tool.

Measurements

The algorithm was measured for content and face validity. Content validity was measured by calculating the content validity index of each component (I-CVI) of the algorithm and the overall scale validity index (S-CVI). Face validity was assessed by calculating the percentage of positive responses to the face validity statements.

Methods

A draft algorithm was developed based on literature searches and expert opinion and validated by interviewing nephrology and pain management clinicians. Through consecutive rounds of 1:1 interviews, content and face validity were assessed by asking participants to rate the relevance of each component of the algorithm and indicate their level of agreeability with a series of statements. Following each round, the I-CVI of the algorithm as well as the S-CVI was calculated and the percentage of positive responses to the statements was determined. The research team revised the algorithm in response to the findings. The final algorithm provides a stepwise approach to the non-pharmacologic and pharmacologic management of pain, including topical, oral, and opioid use.

Results

A total of 18 clinicians from 7 institutions across the Greater Toronto and Hamilton Area were interviewed (10 pharmacists, 5 nurse practitioners, and 3 physicians). The average S-CVI of the algorithm across all 3 rounds was 0.93. At least 78% of participants provided positive responses to the face validity statements.

Limitations

An algorithm was developed based on input from clinicians working in the province of Ontario, limiting the generalizability of the algorithm across provinces. In addition, the algorithm did not include the perspectives of primary care providers or patients/caregivers.

Conclusions

An algorithm for the management of osteoarthritis pain in the hemodialysis population was developed and validated through expert review to standardize practices and encourage clinicians to use evidence-based treatments and address the psychosocial symptoms of pain. As the algorithm possesses a high degree of content and face validity, it may improve osteoarthritis pain management among patients undergoing hemodialysis. Future research will assess the implementation of the algorithm across hemodialysis settings.

Sub-acute pain after childbirth during COVID-19 pandemic: A secondary analysis of A prospective clinical trial

Background

COVID-19 pandemic could bring great impact upon the psychological statuses of post-partum women, but no clear evidence was provided yet as to COVID-19 would also affect their pain profile during post-partum period. We determined if pain and psychological vulnerabilities, obstetric factors, and labor analgesia were associated with sub-acute pain after childbirth (SAPC; ongoing pain related to delivery at post-partum 4 weeks or more) during COVID-19 pandemic.

Methods

We included women having a singleton pregnancy of ≥36 gestational weeks. The recruited women were given pre-delivery questionnaires to measure their pain and psychological vulnerabilities. At post-partum 6-10 weeks, an online survey was conducted to collect data on post-partum pain information.

Results

Of the 880 recruited women, 816 completed the post-partum pain survey, with 99 (12.1%) having developed SAPC. Giving birth during COVID-19 pandemic (adjusted odds ratio (aOR) 1.64, 95%CI 1.04 to 2.57), greater pre-delivery central sensitization (aOR 1.02, 95%CI 1.00 to 1.04), greater number of pain relief administered (aOR 1.49, 95%CI 1.18 to 1.89), having had artificial rupture of membrane and oxytocic during labor onset (aOR 3.00, 95%CI 1.66 to 5.40), greater volume of blood loss during delivery (every 100 ml; aOR 1.27, 95%CI 1.11 to 1.44), having had third-degree tear during delivery (aOR 4.40, 95%CI 1.33 to 14.51), and greater infant height (aOR 1.14, 95%CI 1.01 to 1.30) were independently associated with greater risk of SAPC. Having greater general health score was protective against the risk of SAPC (aOR 0.99, 95% CI 0.97 to 0.999) (Area under the curve (AUC) = 0.74).

Conclusions

The generated multivariable association model may help us better understand the shift in pain and psychological aspects of women during COVID-19 pandemic.

The effect of recorded music on pain endurance (CRESCENDo) - A randomized controlled trial

INTRODUCTION

Clarifying the effect of music on pain endurance in an experimental design could aid in how music should be applied during both surgical and non-surgical interventions. This study aims to investigate the effect of music on pain endurance and the involvement of the sympathetic adrenomedullary axis (SAM) and the hypothalamic-pituitary-adrenocortical axis (HPA).

MATERIALS AND METHODS

In this randomized controlled trial all participants received increasing electric stimuli through their non-dominant index finger. Participants were randomly assigned to the music group (M) receiving a 20-minute music intervention or control group (C) receiving a 20-minute resting period. The primary outcome was pain endurance, defined as amount milliampere tolerated. Secondary outcomes included anxiety level, SAM-axis based on heart rate variability (HRV) and salivary alpha-amylase, and HPA-axis activity based on salivary cortisol.

RESULTS

In the intention-to-treat analysis, the effect of music on pain tolerance did not statistically differ between the M and C group. A significant positive effect of music on pain endurance was noted after excluding participants with a high skin impedance (p = 0.013, CI 0.35; 2.85). Increased HRV was observed in the M-group compared to the C-group for SDNN (B/95%CI:13.80/2.22;25.39, p = 0.022), RMSSD (B/95%CI:15.97/1.64;30.31, p = 0.032), VLF (B/95%CI:212.08/60.49;363.67, p = 0.008) and HF (B/95%CI:821.15/150.78;1491.52, p = 0.0190). No statistical significance was observed in other secondary outcomes.

CONCLUSIONS

The effect of the music intervention on pain endurance was not statistically significant in the intention-to-treat analysis. The subgroup analyses revealed an increase in pain endurance in the music group after correcting for skin impedance, which could be attributed to increased parasympathetic activation.

Relevance of cortisol and copeptin blood concentration changes in an experimental pain model

The effect of pain and analgesics on stress biomarkers is not well studied. We evaluated the effect of acute pain and analgesics on serum cortisol and copeptin in an experimental pain model in healthy volunteers. Healthy volunteers presented at 8 a.m. for an experimental pain stimulation. Cortisol and copeptin levels were measured before, during and after electrophysiological stimulation, first before and then during opioid delivery. Difference in biomarker levels compared to baseline levels was calculated, and potential influencing factors were evaluated by linear regression analysis. Cortisol decreased by 13% during the 10 min of rest at baseline, but copeptin did not change significantly. Cortisol had a median decrease of −24% or −83 nmol/l (−44 to −124 nmol/l, p = 0.0002) during the electrophysiological stimulation training session, while the median difference for copeptin was −22% or −1.01 pmol/l (−2.35 to 0.08 pmol/l, p = 0.0003). After administration of opioids, cortisol did not decrease but increased by 3% (p = 0.043), indicating an increasing opioids effect on cortisol. This effect was not visible for copeptin (median change −0.003 pmol/l (−0.50 to 0.24), p = 0.45). In this experimental pain model performed in the morning, moderate pain did not have a relevant effect on cortisol or copeptin levels, whereas opioids led to a discrete peak of cortisol.

Clinicaltrials.gov identifier: NCT01975753 (registered on November 5, 2013, before start of recruitment).

Posttraumatic Stress Disorder and Persistent Somatic Symptoms During the COVID-19 Pandemic: The Role of Sense of Threat

OBJECTIVE

Persistent somatic symptoms, such as pain and fatigue, have been referred to as somatization. Somatization is commonly associated with histories of trauma and posttraumatic stress disorder (PTSD). Although previous research has demonstrated that PTSD can predict somatic problems, there has been no examination of this at the level of PTSD symptom clusters and multidimensional assessment of somatic symptoms. We examined the association between the three International Classification of Disease (11th Edition) PTSD symptom clusters (reexperiencing in the here and now, avoidance, and sense of threat), measured in relation to the COVID-19 pandemic as the stressor, and somatic symptoms while statistically adjusting for confounding variables.

METHODS

Participants were a nationally representative sample of 1041 adults from the general population of the Republic of Ireland. Physical health problems across the domains of pain, gastrointestinal, cardiopulmonary, and fatigue were assessed by the Patient Health Questionnaire, and PTSD symptoms were assessed using the International Trauma Questionnaire.

RESULTS

Sense of threat was associated with the presence of pain (β = 0.254), fatigue (β = 0.332), gastrointestinal (β = 0.234), and cardiovascular symptoms (β = 0.239). Avoidance was associated with pain (β = 0.347). Reexperiencing was not associated with any physical health variable.

CONCLUSIONS

In the context of COVID-19, the sense of threat symptoms in PTSD is most strongly related to somatic problems. Findings suggest that interventions addressing sense of threat symptoms might provide relief from somatization.

An exploratory investigation into the effects of mental defeat on pain threshold, pain rating, pain anticipation, and mood

In chronic pain, mental defeat is considered as a disabling type of self-evaluation triggered by repeated episodes of debilitating pain. This exploratory study experimentally tested the effect of an activated sense of defeat, as well as its interaction with pain catastrophizing, on pain and mood. Participants (N = 71) were allocated to either high or low pain catastrophizing groups and then randomly assigned to receive either defeat or neutral manipulations. A cold pressor task administered before and after the thought manipulation measured pain threshold, alongside visual analogue scales for mental defeat, attention, pain intensity, pain anticipation as well as mood. Thought manipulation checks supported successful defeat activation. Defeat activation was associated with increased negative mood and attentional disengagement from the nociceptive stimuli, irrespective of pain catastrophizing tendency. There were no changes in pain threshold, pain or pain anticipation ratings. The results suggest that mental defeat can be experimentally activated using an autobiographical memory task and that an activated sense of defeat appears to operate independently from pain catastrophizing in influencing mood and attentional disengagement from the nociceptive stimuli. Future research can utilize our experimental approach to evaluate the effect of an activated sense of mental defeat in people with chronic pain, for whom the magnitude of pain, mood and attentional responses may be stronger and broader.

Maintaining musculoskeletal health using a behavioural therapy approach: a population-based randomised controlled trial (the MAmMOTH Study)

Objective

Cognitive–behavioural therapy (CBT) has been shown to be effective in the management of chronic widespread pain (CWP); we now test whether it can prevent onset among adults at high risk.

Methods

A population-based randomised controlled prevention trial, with recruitment through UK general practices. A mailed screening questionnaire identified adults at high risk of CWP. Participants received either usual care (UC) or a short course of telephone CBT (tCBT). The primary outcome was CWP onset at 12 months assessed by mailed questionnaire. There were seven secondary outcomes including quality of life (EuroQol Questionnaire-five dimensions-five levels/EQ-5D-5L) used as part of a health economic assessment.

Results

996 participants were randomised and included in the intention-to-treat analysis of which 825 provided primary outcome data. The median age of participants was 59 years; 59% were women. At 12 months there was no difference in the onset of CWP (tCBT: 18.0% vs UC: 17.5%; OR 1.05; 95% CI 0.75 to 1.48). Participants who received tCBT were more likely to report better quality of life (EQ-5D-5L utility score mean difference 0.024 (95% CI 0.009 to 0.040)); and had 0.023 (95% CI 0.007 to 0.039) more quality-adjusted life-years at an additional cost of £42.30 (95% CI −£451.19 to £597.90), yielding an incremental cost-effectiveness ratio of £1828. Most secondary outcomes showed significant benefit for the intervention.

Conclusions

A short course of tCBT did not prevent onset of CWP in adults at high risk, but improved quality of life and was cost-effective. A low-cost, short-duration intervention benefits persons at risk of CWP.

Trial registration number

ClinicalTrials.gov Registry (NCT02668003).

Diet and companionship modulate pain via a serotonergic mechanism

Treatment of severe chronic and acute pain in sickle cell disease (SCD) remains challenging due to the interdependence of pain and psychosocial modulation. We examined whether modulation of the descending pain pathway through an enriched diet and companionship could alleviate pain in transgenic sickle mice. Mechanical and thermal hyperalgesia were reduced significantly with enriched diet and/or companionship. Upon withdrawal of both conditions, analgesic effects observed prior to withdrawal were diminished. Serotonin (5-hydroxytryptamine, 5-HT) was found to be increased in the spinal cords of mice provided both treatments. Additionally, 5-HT production improved at the rostral ventromedial medulla and 5-HT accumulated at the dorsal horn of the spinal cord of sickle mice, suggesting the involvement of the descending pain pathway in the analgesic response. Modulation of 5-HT and its effect on hyperalgesia was also investigated through pharmaceutical approaches. Duloxetine, a serotonin-norepinephrine reuptake inhibitor, showed a similar anti-nociceptive effect as the combination of diet and companionship. Depletion of 5-HT through p-chlorophenylalanine attenuated the anti-hyperalgesic effect of enriched diet and companionship. More significantly, improved diet and companionship enhanced the efficacy of a sub-optimal dose of morphine for analgesia in sickle mice. These findings offer the potential to reduce opioid use without pharmacological interventions to develop effective pain management strategies.

Cortisol level dysregulation and its prevalence-Is it nature's alarm clock?

This review examines the stress hormone cortisol which plays an important role in regulating and supporting different bodily functions. Disruption in cortisol production has an impact on health and this review looks at a wide range of papers where cortisol has been indicated as a factor in numerous chronic conditions—especially those which are classed as “noncommunicable diseases” (NCDs). Timely detection, screening, and treatment for NCDs are vital to address the growing problem of NCDs worldwide—this would have health and socioeconomic benefits. Interestingly, many of the papers highlight the pro‐inflammatory consequences of cortisol dysregulation and its deleterious effects on the body. This is particularly relevant given the recent findings concerning COVID‐19 where pro‐inflammatory cytokines have been implicated in severe inflammation.

The influence of rat strain on the development of neuropathic pain and comorbid anxio-depressive behaviour after nerve injury

Back-translating the clinical manifestations of human disease burden into animal models is increasingly recognized as an important facet of preclinical drug discovery. We hypothesized that inbred rat strains possessing stress hyper-reactive-, depressive- or anxiety-like phenotypes may possess more translational value than common outbred strains for modeling neuropathic pain. Rats (inbred: LEW, WKY, F344/ICO and F344/DU, outbred: Crl:SD) were exposed to Spared Nerve Injury (SNI) and evaluated routinely for 6 months on behaviours related to pain (von Frey stimulation and CatWalk-gait analysis), anxiety (elevated plus maze, EPM) and depression (sucrose preference test, SPT). Markers of stress reactivity together with spinal/brain opioid receptor expression were also measured. All strains variously developed mechanical allodynia after SNI with the exception of stress-hyporesponsive LEW rats, despite all strains displaying similar functional gait-deficits after injury. However, affective changes reflective of anxiety- and depressive-like behaviour were only observed for F344/DU in the EPM, and for Crl:SD in SPT. Although differences in stress reactivity and opioid receptor expression occurred, overall they were relatively unaffected by SNI. Thus, anxio-depressive behaviours did not develop in all strains after nerve injury, and correlated only modestly with degree of pain sensitivity or with genetic predisposition to stress and/or affective disturbances.

(Neuro)Inflammatory Component May Be a Common Factor in Chronic Widespread Pain and Restless Legs Syndrome

Purpose of Review

Recent studies have linked fibromyalgia (nociplastic pain) and depression to neuroinflammation. Restless legs syndrome (RLS) is highly prevalent in CWP (chronic widespread pain) and FMS (fibromyalgia syndrome) as well as in depression. This review focuses on evidence in the relationship between CWP and RLS and possible common pathophysiological mechanisms.

Recent Findings

CWP is chronic pain spread over various locations of the body and is a cardinal sign of fibromyalgia. Poor sleep quality is a common symptom in fibromyalgia as well as high levels of fatigue, poor cognition, and other associated features which include depression, headache, and abdominal pain. Evidence for a bilateral relationship between pain and sleep deficit is robust. The latest research focus is not only on insomnia symptoms in chronic pain but also on other types of sleep disorders such as RLS which is characterized by complaints of an “urge to move” frequently associated with dysesthesias. These sensations can also have painful characteristics. Thus, there is a possible overlap between these two entities. The high prevalence of RLS (33–54%) in CWP has been shown in several studies. The pathophysiological mechanisms behind CWP and RLS are still not completely known, but there is a rising amount of evidence on proinflammatory and neuroinflammatory processes in CWP. In RLS, there are links to dopaminergic dysfunction and more generally to monoaminergic dysfunctional circuits, BID (brain iron deficiency), altered glutamatergic neurotransmission, and genetic traits. Depression is a common comorbidity as well in CWP as RLS, and proinflammatory mechanisms have also been demonstrated in this condition.

Summary

The association between CWP and RLS is shown to be high and the pathogenesis of both conditions is still not completely understood. Recent research is focusing on proinflammatory and neuroinflammatory processes, not uniquely emerging in fibromyalgia/CWP, but inflammatory features have been found in depression as well as in sleep deficit. Proinflammatory/neuroinflammatory processes may be an underlying, common factor in both CWP and RLS that future research should investigate further.

Mapping migraine to a common brain network

Inconsistent findings from migraine neuroimaging studies have limited attempts to localize migraine symptomatology. Novel brain network mapping techniques offer a new approach for linking neuroimaging findings to a common neuroanatomical substrate and localizing therapeutic targets. In this study, we attempted to determine whether neuroanatomically heterogeneous neuroimaging findings of migraine localize to a common brain network. We used meta-analytic coordinates of decreased grey matter volume in migraineurs as seed regions to generate resting state functional connectivity network maps from a normative connectome (n = 1000). Network maps were overlapped to identify common regions of connectivity across all coordinates. Specificity of our findings was evaluated using a whole-brain Bayesian spatial generalized linear mixed model and a region of interest analysis with comparison groups of chronic pain and a neurologic control (Alzheimer's disease). We found that all migraine coordinates (11/11, 100%) were negatively connected (t ≥ ±7, P < 10-6 family-wise error corrected for multiple comparisons) to a single location in left extrastriate visual cortex overlying dorsal V3 and V3A subregions. More than 90% of coordinates (10/11) were also positively connected with bilateral insula and negatively connected with the hypothalamus. Bayesian spatial generalized linear mixed model whole-brain analysis identified left V3/V3A as the area with the most specific connectivity to migraine coordinates compared to control coordinates (voxel-wise probability of ≥90%). Post hoc region of interest analyses further supported the specificity of this finding (ANOVA P = 0.02; pairwise t-tests P = 0.03 and P = 0.003, respectively). In conclusion, using coordinate-based network mapping, we show that regions of grey matter volume loss in migraineurs localize to a common brain network defined by connectivity to visual cortex V3/V3A, a region previously implicated in mechanisms of cortical spreading depression in migraine. Our findings help unify migraine neuroimaging literature and offer a migraine-specific target for neuromodulatory treatment.

Hypothalamic-Pituitary-Adrenal Axis Responses in Women with Endometriosis-Related Chronic Pelvic Pain

Some chronic pain conditions and comorbidities suppress the hypothalamic-pituitary-adrenal (HPA) axis and response to dynamic testing. We measured HPA axis responses to corticotropin-releasing hormone (CRH) administration in relation to chronic pelvic pain and endometriosis. In a cross-sectional study of women (n = 54) with endometriosis-associated chronic pelvic pain (n = 22), chronic pelvic pain alone (n = 12), or healthy volunteers (n = 20), adrenocorticotropic-releasing hormone (ACTH) and cortisol levels were measured at 0, 15, 30, and 45 min after intravenous ovine CRH administration. ACTH and cortisol delta (peak-baseline) and area under the curve (AUC) were compared by study group and assessed for association with race and menstrual and non-menstrual pain severity. HPA axis responses did not differ among the racially diverse groups or in those with pain compared with healthy volunteers. However, when stratified by race, ACTH delta (129.9 ± 130.7 vs. 52.5 ± 66.0 pg/mL; p = 0.003), ACTH AUC (4813 ± 4707 vs. 2290 ± 2900 min*pg/mL; p = 0.013), and cortisol delta (26.3 ± 21.5 vs. 13.2 ± 9.7 μg/mL; p = 0.005) were significantly higher in black (n = 10) than predominately white (non-black) subjects (n = 44; 39/44 white). In analyses among primarily white (non-black) women, greater menstrual pain severity was associated with blunted ACTH delta (p = 0.015) and cortisol delta (p = 0.023), and greater non-menstrual pain severity with blunted cortisol delta (p = 0.017). Neuroendocrine abnormalities in women with chronic pelvic pain may differ by pain manifestations and may vary by race. The higher HPA axis response in black women merits investigation in pelvic pain studies stratified by race. In white (non-black) women experiencing pain, a blunted response was related to pain severity suggesting pain affects women independently of endometriosis lesions.

Examination and characterisation of burst spinal cord stimulation on cerebrospinal fluid cellular and protein constituents in patient responders with chronic neuropathic pain - A Pilot Study

INTRODUCTION

Patients with neuropathic pain have altered proteomic and neuropeptide constituents in cerebrospinal fluid (CSF) compared to controls. Tonic spinal cord stimulation (SCS) has demonstrated differential expression of neuropeptides in CSF before and after treatment suggesting potential mechanisms of action. Burst-SCS is an evidence-based paraesthesia free waveform utilised for neuropathic pain with a potentially different mechanistic action to tonic SCS. This study examines the dynamic biological changes of CSF at a cellular and proteome level after Burst-SCS.

METHODS

Patients with neuropathic pain selected for SCS had CSF sampled prior to implant of SCS and following 8 weeks of continuous Burst-SCS. Baseline and 8-week pain scores with demographics were recorded. T cell frequencies were analysed by flow cytometry, proteome analysis was performed using mass spectrometry and secreted cytokines, chemokines and neurotrophins were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

4 patients (2 females, 2 males) with a mean age of 51 years (+/-SEM 2.74, SD 5.48) achieved a reduction in pain of >50% following 8 weeks of Burst-SCS. Analysis of the CSF proteome indicated a significant alteration in protein expression most related to synapse assembly and immune regulators. There was significantly lower expression of the proteins: growth hormone A1 (PRL), somatostatin (SST), nucleobindin-2 (NUCB2), Calbindin (CALB1), acyl-CoA binding protein (DBI), proSAAS (PCSK1N), endothelin-3 (END3) and cholecystokinin (CCK) after Burst-SCS. The concentrations of secreted chemokines and cytokines and the frequencies of T cells were not significantly changed following Burst-SCS.

CONCLUSION

This study characterised the alteration in the CSF proteome in response to burst SCS in vivo. Functional analysis indicated that the alterations in the CSF proteome is predominately linked to synapse assembly and immune effectors. Individual protein analysis also suggests potential supraspinal mechanisms.

Intraindividual variability in sleep and comorbid medical and mental health conditions

STUDY OBJECTIVES

Intraindividual variability (IIV) in sleep may be a risk factor for disease above the influence of mean sleep. Associations between IIV in sleep and risk for a comprehensive set of common medical and mental health conditions have not been assessed in a representative sample.

METHODS

This study examined mean and IIV in total sleep time (TST), sleep quality (SQ), sleep efficiency (SE), and circadian midpoint (CM) in 771 adults recruited for an epidemiological study. Participants completed 14 days of sleep diaries to assess TST, SQ, SE, and CM, after which they reported on medical conditions and mental health symptoms. Data were analyzed using logistic regression, and models controlled for gender, body mass index, age, and race.

RESULTS

Lower mean TST, SQ, and SE were related to increased odds of having gastrointestinal problems, depression, and anxiety. IIV in TST was related to increased odds of having neurological, breathing, and gastrointestinal problems, as well as pain and depression; all results held controlling for mean sleep and adjusting for false discovery rate. IIV in SQ and SE was not associated with odds of having any medical or mental health conditions after adjusting for false discovery rate, nor was IIV in CM or mean CM.

CONCLUSIONS

Confirming previous research, mean TST, SQ, and SE are related to risk for gastrointestinal problems, depression, and anxiety. IIV in TST may be a unique facet of disturbed sleep that is associated with increased risk for a diverse cluster of medical and mental health conditions.

Factors Associated with the Development of Postnatal Depression After Cesarean Delivery: A Prospective Study

PURPOSE

Pre-operative association factors (pain and psychological vulnerability) could significantly contribute to post-Cesarean pain; however, limited information is available on the development of postnatal depression (PND). We aimed to investigate the development of PND and its association with pain vulnerability and psychological vulnerability factors.

PATIENTS AND METHODS

Women undergoing Cesarean delivery under spinal anesthesia were given pre-operative questionnaires, psychological and pain assessments including pain on local anesthetic injection during spinal anesthesia and mechanical temporal summation. Post-operative assessments were administered at 6 to 10 weeks post-Cesarean delivery via follow-up survey to assess post-Cesarean psychological and pain outcomes.

RESULTS

PND occurred in 21.1% (43 of 205) of patients who underwent elective Cesarean delivery. An increased pre-operative pain score with movement (Odds ratio (OR) 1.65, 95% CI 1.12-2.44, p = 0.0110), anxiety about upcoming surgery (OR 1.02, 95% CI 1.00-1.04, p = 0.0429), higher pre-operative Hospital Anxiety and Depression Scale (HADS) subscale on anxiety (OR 1.25, 95% CI 1.07-1.45, p = 0.0041) and higher pre-operative central sensitization inventory (CSI) scores (OR 1.05, 95% CI 1.01-1.09, p = 0.0156) were independently associated with an increased risk of PND. Anticipated pain medication needs were associated with reduced risk of PND (OR 0.48, 95% CI 0.29-0.79, p = 0.0038) (Receiver operating characteristic (ROC) = 0.8177).

CONCLUSION

Higher pre-operative anxiety, pain score, central sensitization and lower anticipated pain medication needs were associated with increased risks of PND. Further work using larger sample size will be needed to validate the model in predicting PND development after Cesarean delivery.

The Role of Patient and Parental Resilience in Adolescents with Chronic Musculoskeletal Pain

OBJECTIVES

To assess the level of resilience among patients with chronic musculoskeletal pain and their parents and to determine factors associated with patient and parental resilience.

STUDY DESIGN

Cross-sectional cohort study of children aged 13-17 years diagnosed with chronic musculoskeletal pain and their parents. Patient-parent pairs were seen for initial consultation in the pediatric rheumatology pain clinic at Children's Hospital of Philadelphia between March and May 2018 and were administered a series of questionnaires including measures of resilience (Connor-Davidson Resilience Scale 10 item, The 14-item Resilience Scale, and the 7Cs of Resilience Tool). We calculated Pearson correlation coefficients to examine the relationship between the variables of interest and resilience.

RESULTS

According to all resilience measures, patients and parents had low to moderate levels of resilience. These levels were lower than those previously reported among healthy populations, as well as those with chronic medical conditions. According to the Connor-Davidson Resilience Scale 10 item, patient-level resilience was negatively correlated with pain level (r = -0.48), physical disability (r = -0.54), and symptom severity (r = -0.53). The level of resilience among patients was positively correlated with energy level (r = 0.57) and health-related quality of life (r = 0.64). Parental resilience was positively correlated with parental mental health (r = 0.61).

CONCLUSIONS

Higher patient resilience was correlated with reduced disease severity among adolescents with chronic musculoskeletal pain. Future research should explore whether fostering resilience in adolescents with chronic musculoskeletal pain via the application of resilience-training interventions mitigates disease burden in this vulnerable patient population.

Child Abuse and Neglect as Risk Factors for Comorbidity Between Depression and Chronic Pain in Adulthood

It is estimated that comorbidity between depression and chronic pain reaches more than half of the depressed adult patients around the world. Evidence indicates that some stressors, such as early-life stress (ELS), mediate the co-occurrence of depression and chronic pain. This study aimed to assess whether ELS or any of its subtypes could be considered as risk factors for comorbidity between depression and chronic pain. For this purpose, 44 patients in depressive episode were evaluated, in which 22 were diagnosed with depression and chronic pain, and the other 22 patients were diagnosed with depression but without chronic pain. Results had shown that ELS occurrence is more significant among depressive patients with chronic pain compared with those without pain. When subtypes of ELS were evaluated, the group of depressive patients with pain showed significantly higher prevalence of emotional neglect than those depressive participants without pain. Data analysis has shown that severity of the depressive symptoms has a significant impact on the total score of childhood trauma, emotional abuse, physical abuse, emotional neglect, and physical neglect, and that emotional abuse, sexual abuse, and physical neglect have significant impact on the severity of depression. In conclusion, our findings indicate that ELS can be considered as a risk factor for the comorbidity between depression and chronic pain.

Leukocyte coping capacity chemiluminescence as an innovative tool for stress and pain assessment in calves undergoing ring castration

Pain and stress assessment in animals is considered an imperative issue and also a difficult challenge. Unfortunately, no gold standard technique for pain and stress assessment in animals has been validated nowadays. A new tool to assess stress in animals consists of measuring the leukocyte coping capacity (LCC). The aim of this study was to evaluate the whole-blood LCC chemiluminescence as an innovative tool for stress and pain assessment in the bovine species undergoing ring castration. Twenty 2-mo-old male mix-breed Piemontese-Angus-Belgian Blue calves (Bos taurus) weighing 90 ± 4 kg were used. The animals were randomly allocated in 2 groups composed of 10 subjects each as follows: ring castration group (CAS) and sham castration group (SHAM). Blood drawing, scrotal and perineal temperature recording, scrotal lesion score, pain assessment, and LCC Chemiluminescence were performed at different time points, which were as follows: 1 h before castration/sham (-1 h), 30 min postcastration/sham (30 min), 3 d postcastration/sham (3 d), 7 d postcastration/sham (7 d), 14 d postcastration/sham (14 d). Results showed that in CAS LCC values significantly increased (P < 0.05) at 3 d and decreased at 7 d, whereas in SHAM, LCC values did not significantly vary between the study times. Significant differences in LCC values between CAS and SHAM were seen at 7 d (P < 0.0001). In the CAS group, scrotal lesion was scored as 0, 0, 3.8, 2.7, and 0.2 at -1 h, 30 min, 3 d, 7 d, and 14 d, respectively, whereas in SHAM, its score was 0 at every time point. Perineal temperatures did not vary throughout all the study times in both CAS and SHAM. Differences among the 2 groups were noted in scrotal temperatures only at 3, 7, and 14 d (P < 0.05). In CAS, the percentage of animals which obtained a pain score ≥ 1 was: 10% at -1 h, 30% at 30 min, 20% at 3 and 7 d, and 10% at 14 d, whereas in SHAM, no pain signs were noted at any time point. No significant difference between CAS and SHAM was recorded in cortisol blood level at any time point. No stress leukogram nor variation in neutrophil/lymphocyte ratio was noted at any of the time points in both CAS or SHAM. Our results suggest that ring castration might cause long-lasting pain in calves, but its magnitude is not easily detected by conventional methods. We argue that whole-blood LCC chemiluminescence might be a useful tool for detecting pain and stress in calves undergoing ring castration.

Biological Mechanisms of Cancer-Induced Depression

Patients with cancer are more likely to develop depression than the general population, which negatively impacts their quality of life and prognosis. In order to identify effective antidepressants catered toward cancer patients, the biology of depression in the context of cancer must be well-understood. Many theories have emerged postulating the mechanisms underlying the development of depressive disorder. Here, we review the role inflammation, a hyperactive hypothalamic-pituitary-adrenal (HPA) axis, and glutamate excitotoxicity may play in cancer-induced depression. Hopefully, novel therapeutics targeting these dysregulated pathways may be potent in ameliorating depressive symptoms in the cancer population.

Morning cortisol and fasting glucose are elevated in women with chronic widespread pain independent of comorbid restless legs syndrome

Background and aims:

Chronic widespread pain (CWP) is associated with poor quality of sleep, but the detailed underlying mechanisms are still not fully understood. In this study we investigated the influence of CWP on morning cortisol and fasting glucose concentrations as well as sleep disordered breathing.

Methods:

In this case-control study, subjects with CWP (n=31) and a control group without CWP (n=23) were randomly selected from a population-based cohort of women. Current pain intensity, sleep quality, excessive daytime sleepiness [Epworth sleepiness scale (ESS)], psychiatric comorbidity and occurrence of restless legs syndrome (RLS) were assessed. Overnight polygraphy was applied to quantify sleep apnoea, airflow limitation and attenuations of finger pulse wave amplitude (>50%) as a surrogate marker for increased skin sympathetic activity. Morning cortisol and fasting glucose concentrations were determined. Generalised linear models were used for multivariate analyses.

Results:

CWP was associated with higher cortisol (464±141 vs. 366±111 nmol/L, p=0.011) and fasting glucose (6.0±0.8 vs. 5.4±0.7 mmol/L, p=0.007) compared with controls. The significance remained after adjustment for age, body mass index, RLS and anxiety status (β=122±47 nmol/L and 0.89±0.28 mmol/L, p=0.009 and 0.001, respectively). The duration of flow limitation in sleep was longer (35±22 vs. 21±34 min, p=0.022), and pulse wave attenuation was more frequent (11±8 vs. 6±2 events/h, p=0.048) in CWP subjects compared with controls. RLS was associated with higher ESS independent of CWP (β=3.1±1.3, p=0.018).

Conclusions:

Elevated morning cortisol, impaired fasting glucose concentration and increased skin sympathetic activity during sleep suggested an activated adrenal medullary system in subjects with CWP, which was not influenced by comorbid RLS.

Implications:

CWP is associated with activated stress markers that may deteriorate sleep.

Self-reported Chronic Pain in Young Adults With a Low Birth Weight

OBJECTIVE

To investigate self-reported pain in young adults with a low birth weight.

MATERIALS AND METHODS

This study was a part of a long-term follow-up study of preterm very low birth weight (VLBW; birth weight ≤1500 g), term small for gestational age (SGA; birth weight <10th percentile adjusted for sex and parity), and control young adults born during 1986 to 1988. Of the 300 individuals invited, 216 (62 VLBW, 67 term SGA, and 87 controls) completed a pain questionnaire. Of these, 151 (70%) had answered a pain severity question at 19 years. Chronic pain was defined as pain lasting for >6 months and being moderate, severe, or very severe during the past 4 weeks.

RESULTS

The prevalence of chronic pain at 26 years was 16% in the VLBW group, 21% in the term SGA group, and 7% in the control group. The VLBW and the term SGA groups had higher odds ratios for chronic pain (crude OR, 2.6; 95% CI, 0.9-7.6 for the VLBW group and crude OR, 3.6; 95% CI, 1.3-9.9 for the term SGA group vs. controls). The main results remained after adjusting for potential confounding factors. Some attenuation was observed when adjusting for anxiety and depressive problems. Moderate to very severe pain increased from 16% to 41% in the term SGA group from 19 to 26 years, whereas less changes were seen in the VLBW and the control groups.

DISCUSSION

Results of our study imply that pain should be in focus when conducting long-term follow-up programs of individuals with a low birth weight.

Religious Service Attendance and Lower Depression Among Women-a Prospective Cohort Study

OBJECTIVE

Previous studies on the association between religious service attendance and depression have been mostly cross-sectional, subject to reverse causation, and did not account for the potential feedback between religious service attendance and depression. We prospectively evaluated evidence whether religious service attendance decreased risk of subsequent risk of depression and whether depression increased subsequent cessation of service attendance, while explicitly accounting for feedback with potential effects in both directions.

METHOD

We included a total of 48,984 US nurses who were participants of the Nurses' Health Study with mean age 58 years and who were followed up from 1996 to 2008. Religious service attendance was self-reported in 1992, 1996, 2000, and 2004. Depression was defined as self-reported physician-diagnosed clinical depression, regular anti-depressant use, or severe depressive symptoms. Multivariate logistic regression and marginal structural models were used to estimate the odds ratio of developing incident depression, adjusted for baseline religious service attendance, baseline depression, and time-varying covariates.

RESULTS

Compared with women who never attended services, women who had most frequent and recent religious service attendance had the lowest risk of developing depression (odds ratio [OR] = 0.71, 95 % confidence interval [CI] 0.62-0.82). Compared with women who were not depressed, women with depression were less likely to subsequently attend religious services once or more per week (OR = 0.74, 95 % CI 0.68-0.80).

CONCLUSIONS

In this study of US women, there is evidence that higher frequency of religious service attendance decreased the risk of incident depression and women with depression were less likely to subsequently attend services.

Possible modulation of PPAR-γ cascade against depression caused by neuropathic pain in rats

BACKGROUND

Sciatic nerve ligation causes neuropathic pain with chronic constriction injury (CCI). However, there is no published report on the effect of pioglitazone as an antidepressant in the treatment of depression induced by neuropathic pain with CCI in rats. The aim of this study was to evaluate the effect of pioglitazone as an antidepressant by targeting oxidative stress by the peripheral neuropathic pain model using the CCI of the sciatic nerve.

METHODS

Behavioral studies were carried out to measure thermal hyperalgesia and cold allodynia as markers of neuropathic pain and force swim test for depression. These were followed by estimation of biochemical parameters which include lipid peroxidation (LPO), reduced glutathione, catalase, nitrite and superoxide dismutase (SOD) in the rat brains as a measure of oxidative stress. We administered two intraperitoneal doses of pioglitazone (4.5 and 9.0 mg/kg, i.p.) to the treated group for 28 consecutive days from the day of injury and behavioral as well as biochemical evaluations were performed.

RESULTS

The results suggested that the administration of pioglitazone significantly countered the neuropathic pain induced depression as interpreted through elevated pain threshold of tactile allodynia and thermal hyperalgesia followed by decreased immobility time in the 9.0 mg/kg dose group.

CONCLUSIONS

It may be concluded that the oxidative stress plays a critical role in the pathogenesis of neuropathic pain and depression as evidenced by the behavioral studies and the changes in the levels of lipid peroxidase, nitrite, catalase, and glutathione and SOD.

Depression and Pain in Asian and White Americans With Knee Osteoarthritis

Few studies have examined the underlying psychosocial mechanisms of pain in Asian Americans. Using the biopsychosocial model, we sought to determine whether variations in depression contribute to racial group differences in symptomatic knee osteoarthritis pain between Asian Americans and non-Hispanic white Americans. The sample consisted of 100 participants, including 50 Asian Americans (28 Korean Americans, 9 Chinese Americans, 7 Japanese Americans, 5 Filipino Americans, and 1 Indian American) and 50 age- and sex-matched non-Hispanic white Americans with symptomatic knee osteoarthritis pain. The Centers for Epidemiologic Studies Depression Scale was used to assess symptoms of depression, and the Western Ontario and McMaster Universities Osteoarthritis Index and the Graded Chronic Pain Scale were used to measure clinical pain. In addition, quantitative sensory testing was used to measure experimental sensitivity to heat- and mechanically-induced pain. The results indicated that higher levels of depression in Asian Americans may contribute to greater clinical pain and experimental pain sensitivity. These findings add to the growing literature regarding ethnic and racial differences in pain and its associated psychological conditions, and additional research is warranted to strengthen these findings.

PERSPECTIVE

This article shows the contribution of depression to clinical pain and experimental pain sensitivity in Asian Americans with knee osteoarthritis. Our results suggest that Asian Americans have higher levels of depressive symptoms and that depression plays a relevant role in greater clinical pain and experimental pain sensitivity in Asian Americans.

Neuroplasticity of Supraspinal Structures Associated with Pathological Pain

Peripheral nerve and spinal cord injuries, along with other painful syndromes such as fibromyalgia, diabetic neuropathy, chemotherapeutic neuropathy, trigeminal neuralgia, complex regional pain syndrome, and/or irritable bowel syndrome, cause several neuroplasticity changes in the nervous system along its entire axis affecting the different neuronal nuclei. This paper reviews these changes, focusing on the supraspinal structures that are involved in the modulation and processing of pain, including the periaqueductal gray matter, red nucleus, locus coeruleus, rostral ventromedial medulla, thalamus, hypothalamus, basal ganglia, cerebellum, habenula, primary, and secondary somatosensory cortex, motor cortex, mammillary bodies, hippocampus, septum, amygdala, cingulated, and prefrontal cortex. Hyperexcitability caused by the modification of postsynaptic receptor expression, central sensitization, and potentiation of presynaptic delivery of neurotransmitters, as well as the reduction of inhibitory inputs, changes in dendritic spine, neural circuit remodeling, alteration of gray matter, and upregulation of proinflammatory mediators (e.g., cytokines) by reactivation of astrocytes and microglial cells are the main functional, structural, and molecular neuroplasticity changes observed in the above supraspinal structures, associated with pathological pain. Studying these changes in greater depth may lead to the implementation and improvement of new therapeutic strategies against pathological pain. Anat Rec, 300:1481-1501, 2017. © 2017 Wiley Periodicals, Inc.

Lifetime Modulation of the Pain System via Neuroimmune and Neuroendocrine Interactions

Chronic pain is a debilitating condition that still is challenging both clinicians and researchers. Despite intense research, it is still not clear why some individuals develop chronic pain while others do not or how to heal this disease. In this review, we argue for a multisystem approach to understand chronic pain. Pain is not only to be viewed simply as a result of aberrant neuronal activity but also as a result of adverse early-life experiences that impact an individual's endocrine, immune, and nervous systems and changes which in turn program the pain system. First, we give an overview of the ontogeny of the central nervous system, endocrine, and immune systems and their windows of vulnerability. Thereafter, we summarize human and animal findings from our laboratories and others that point to an important role of the endocrine and immune systems in modulating pain sensitivity. Taking "early-life history" into account, together with the past and current immunological and endocrine status of chronic pain patients, is a necessary step to understand chronic pain pathophysiology and assist clinicians in tailoring the best therapeutic approach.

Long-term adolescent multi-site musculoskeletal pain is associated with psychological distress and anxiety

OBJECTIVE

Although several studies have shown that adolescent musculoskeletal pain is associated with psychological problems in a cross-sectional setting, the associations of long-term musculoskeletal pain with psychological distress and anxiety are not known.

METHODS

The study included 1773 adolescents belonging to the Northern Finland Birth Cohort 1986. They received a postal questionnaire at the age of 16years and a follow-up questionnaire two years later. The first inquiry contained questions about the sites of musculoskeletal pain; the second had the same pain questions, along with measures of distress and anxiety. Risk ratios (RR) were assessed by log-linear regression analysis.

RESULTS

Multi-site musculoskeletal pain (in ≥2 body locations) at both 16 and 18years was common, reported by 53% of girls and 30% of boys. Multi-site pain at both ages, compared to those with multi-site pain neither at 16 nor 18years, was associated with psychological distress at the age of 18 among both girls (RR 1.8 95% CI 1.2-2.7) and boys (RR 3.5 95% CI 2.1-5.9). For anxiety, the corresponding relative risks were 1.5 (95% CI 1.0-2.2) and 1.8 (95% CI 1.4-2.3), respectively. For short-term multi-site pain (prevalent only at the age of 16 or 18), these relative risks were between 0.8 and 2.3.

CONCLUSIONS

Adolescents with long-term multi-site pain have higher levels of distress and anxiety than those without or with only short-term multi-site pain. Associations were found in both genders, but the relationship between pain and distress was more pronounced among boys. The associations had modest effect strength.

Potential pleiotropic beneficial effects of adjuvant melatonergic treatment in posttraumatic stress disorder

Loss of circadian rhythmicity fundamentally affects the neuroendocrine, immune, and autonomic system, similar to chronic stress and may play a central role in the development of stress-related disorders. Recent articles have focused on the role of sleep and circadian disruption in the pathophysiology of posttraumatic stress disorder (PTSD), suggesting that chronodisruption plays a causal role in PTSD development. Direct and indirect human and animal PTSD research suggests circadian system-linked neuroendocrine, immune, metabolic and autonomic dysregulation, linking circadian misalignment to PTSD pathophysiology. Recent experimental findings also support a specific role of the fundamental synchronizing pineal hormone melatonin in mechanisms of sleep, cognition and memory, metabolism, pain, neuroimmunomodulation, stress endocrinology and physiology, circadian gene expression, oxidative stress and epigenetics, all processes affected in PTSD. In the current paper, we review available literature underpinning a potentially beneficiary role of an add-on melatonergic treatment in PTSD pathophysiology and PTSD-related symptoms. The literature is presented as a narrative review, providing an overview on the most important and clinically relevant publications. We conclude that adjuvant melatonergic treatment could provide a potentially promising treatment strategy in the management of PTSD and especially PTSD-related syndromes and comorbidities. Rigorous preclinical and clinical studies are needed to validate this hypothesis.

Resilience moderates the association between chronic pain and depressive symptoms in the elderly

BACKGROUND

Chronic pain is frequent in elderly people and, especially if widespread, associated with poor mental health. We investigated whether a resilient personality protects older adults against the adverse effects of chronic pain.

METHODS

Pain status [no pain, chronic local pain (CLP) and chronic widespread pain (CWP)] was determined using the American College of Rheumatologists' criteria for widespread pain in a cross-sectional sample of 724 participants aged 68-92 years drawn from the population-based KORA-Age study in Southern Germany. Depressive symptoms and resilience were assessed via the scales GDS-15 and RS-5. The relation between pain, resilience and depressive symptoms was modelled using logistic and quantile regression.

RESULTS

CLP prevalence and CWP prevalence were 57.5% and 12.3%, respectively. Confounder-adjusted logistic regression indicated a fourfold risk of depressed mood (GDS-15 ≥ 5) in CWP, vs. no pain (OR = 4.08, 95% CI 1.90-8.74). However, in quantile regression, the adverse effect of CWP was significantly attenuated by resilience when looking at the GDS-15 score lower quartile (p = 0.011) and median (p = 0.011). This effect appeared to be mainly driven by participants aged 75-84 years. Confounder adjustment reduced the effect of CLP on depressive symptoms to non-significance, and effect modification by resilience was undetectable in regression models of CLP.

CONCLUSIONS

Resilience was protective in the association of CWP with depressive symptoms in this analysis. Older adults with CWP may potentially benefit from interventions supporting resilience. Prospective research should investigate the protective role of resilience in the potentially self-perpetuating relation between chronic pain and depressed affect. WHAT DOES THIS STUDY ADD?: The association of chronic widespread pain with depressive symptoms in the elderly population is attenuated by resilience.

A clinical survey of pain in Parkinson's disease in Eastern China

BACKGROUND

This is a case-control study to investigate the prevalence, characteristics, and risk factors of pain in patients with Parkinson's disease (PD).

METHODS

A total of 200 PD patients from eastern China were enrolled in our study. Accordingly, 200 healthy elderly adults were recruited as controls. The characteristics of pain were collected by using the Visual Analog Scale, Brief Pain Inventory (BPI), SF-36 Bodily Pain Scale, Unified Parkinson's Disease Rating Scale, Hoehn-Yahr Scale (H-Y), Hamilton Depression Scale, and Leeds Assessment of Neuropathic Symptoms and Signs.

RESULTS

Of the 200 PD patients, pain was complained by 106 patients (53%). According to the SF-36 Bodily Pain Scale, pain morbidity in PD patients was significantly higher than in the control group. The average pain during last 24 h measured by the BPI was 2.67. About 76% of PD patients were found to have one pain type, 21.7% were having two pain types, and 1.9% had three pain types. Further, 69.8% of these patients were presented with musculoskeletal pain, 4.7% with dystonic pain, 22.6% with radicular-neuropathic pain, 20.8% with central neuropathic pain, and 9.4% with akathisia pain. The onset age and depression were the most significant predictors of pain in PD patients (p < 0.05). However, there was no significant association between pain and gender, age, disease duration, or severity of the disease. Only 5.7% of PD patients with pain received treatment in this study.

CONCLUSIONS

Pain is frequent and disabling, independent of demographic and clinical variables, and is significantly more common in PD patients.

High Times for Painful Blues: The Endocannabinoid System in Pain-Depression Comorbidity

Depression and pain are two of the most debilitating disorders worldwide and have an estimated cooccurrence of up to 80%. Comorbidity of these disorders is more difficult to treat, associated with significant disability and impaired health-related quality of life than either condition alone, resulting in enormous social and economic cost. Several neural substrates have been identified as potential mediators in the association between depression and pain, including neuroanatomical reorganization, monoamine and neurotrophin depletion, dysregulation of the hypothalamo-pituitary-adrenal axis, and neuroinflammation. However, the past decade has seen mounting evidence supporting a role for the endogenous cannabinoid (endocannabinoid) system in affective and nociceptive processing, and thus, alterations in this system may play a key role in reciprocal interactions between depression and pain. This review will provide an overview of the preclinical evidence supporting an interaction between depression and pain and the evidence supporting a role for the endocannabinoid system in this interaction.

Salivary cortisol and cold pain sensitivity in female twins

BACKGROUND

There is a dearth of knowledge about the link between cortisol and pain sensitivity.

PURPOSE

We examined the association of salivary cortisol with indices of cold pain sensitivity in 198 female twins and explored the role of familial confounding.

METHODS

Three-day saliva samples were collected for cortisol levels and a cold pressor test was used to collect pain ratings and time to threshold and tolerance. Linear regression modeling with generalized estimating equations examined the overall and within-pair associations.

RESULTS

Lower diurnal variation of cortisol was associated with higher pain ratings at threshold (p = 0.02) and tolerance (p < 0.01). The relationship of diurnal variation with pain ratings at threshold and tolerance was minimally influenced by familial factors (i.e., genetics and common environment).

CONCLUSIONS

Understanding the genetic and non-genetic mechanisms underlying the link between HPA axis dysregulation and pain sensitivity may help to prevent chronic pain development and maintenance.

Correlation between the cumulative analgesic effect of electroacupuncture intervention and synaptic plasticity of hypothalamic paraventricular nucleus neurons in rats with sciatica

In the present study, a rat model of chronic neuropathic pain was established by ligation of the sciatic nerve and a model of learning and memory impairment was established by ovariectomy to investigate the analgesic effect of repeated electroacupuncture stimulation at bilateral Zusanli (ST36) and Yanglingquan (GB34). In addition, associated synaptic changes in neurons in the paraventricular nucleus of the hypothalamus were examined. Results indicate that the thermal pain threshold (paw withdrawal latency) was significantly increased in rats subjected to 2-week electroacupuncture intervention compared with 2-day electroacupuncture, but the analgesic effect was weakened remarkably in ovariectomized rats with chronic constrictive injury. 2-week electroacupuncture intervention substantially reversed the chronic constrictive injury-induced increase in the synaptic cleft width and thinning of the postsynaptic density. These findings indicate that repeated electroacupuncture at bilateral Zusanli and Yanglingquan has a cumulative analgesic effect and can effectively relieve chronic neuropathic pain by remodeling the synaptic structure of the hypothalamic paraventricular nucleus.

Central changes associated with chronic pelvic pain and endometriosis

BACKGROUND

Chronic pelvic pain (CPP) is a significant public health problem with 1 million affected women in the UK. Although many pathologies are associated with CPP, the pain experienced is often disproportionate to the extent of disease identified and frequently no pathology is found (chronic pelvic pain syndrome). The central nervous system (CNS) is central to the experience of pain and chronic pain conditions in general are associated with alterations in both the structure and function of the CNS. This review describes the available evidence for central changes in association with conditions presenting with CPP.

METHODS

A detailed literature search was performed to identify relevant papers, however, this is not a systematic review.

RESULTS

CPP is associated with central changes similar to those identified in other pain conditions. Specifically these include, alterations in the behavioural and central response to noxious stimulation, changes in brain structure (both increases and decreases in the volume of specific brain regions), altered activity of both the hypothalamic-pituitary-adrenal axis and the autonomic nervous system (ANS) and psychological distress.

CONCLUSIONS

The evidence reviewed in this paper demonstrates that CPP is associated with significant central changes when compared with healthy pain-free women. Moreover, the presence of these changes has the potential to both exacerbate symptoms and to predispose these women to the development of additional chronic conditions. These findings support the use of adjunctive medication targeting the CNS in these women.

Altered nociceptive, endocrine, and dorsal horn neuron responses in rats following a neonatal immune challenge

The neonatal period is characterized by significant plasticity where the immune, endocrine, and nociceptive systems undergo fine-tuning and maturation. Painful experiences during this period can result in long-term alterations in the neurocircuitry underlying nociception, including increased sensitivity to mechanical or thermal stimuli. Less is known about the impact of neonatal exposure to mild inflammatory stimuli, such as lipopolysaccharide (LPS), on subsequent inflammatory pain responses. Here we examine the impact of neonatal LPS exposure on inflammatory pain sensitivity and HPA axis activity during the first three postnatal weeks. Wistar rats were injected with LPS (0.05mg/kg IP, Salmonella enteritidis) or saline on postnatal days (PNDs) 3 and 5 and later subjected to the formalin test at PNDs 7, 13, and 22. One hour after formalin injection, blood was collected to assess corticosterone responses. Transverse spinal cord slices were also prepared for whole-cell patch clamp recording from lumbar superficial dorsal horn neurons (SDH). Brains were obtained at PND 22 and the hypothalamus was isolated to measure glucocorticoid (GR) and mineralocorticoid receptor (MR) transcript expression using qRT-PCR. Behavioural analyses indicate that at PND 7, no significant differences were observed between saline- or LPS-challenged rats. At PND 13, LPS-challenged rats exhibited enhanced licking (p<.01), and at PND 22, increased flinching in response to formalin injection (p<.05). LPS-challenged rats also displayed increased plasma corticosterone at PND 7 and PND 22 (p<.001) but not at PND 13 following formalin administration. Furthermore, at PND 22 neonatal LPS exposure induced decreased levels of GR mRNA and increased levels of MR mRNA in the hypothalamus. The intrinsic properties of SDH neurons were similar at PND 7 and PND 13. However, at PND 22, ipsilateral SDH neurons in LPS-challenged rats had a lower input resistance compared to their saline-challenged counterparts (p<.05). These data suggest neonatal LPS exposure produces developmentally regulated changes in formalin-induced behavioural responses, corticosterone levels, and dorsal horn neuron properties following noxious stimulation later in life. These findings highlight the importance of immune activation during the neonatal period in shaping pain sensitivity later in life. This programming involves both spinal cord neurons and the HPA axis.

The contribution of stress to the comorbidity of migraine and major depression: results from a prospective cohort study

OBJECTIVES

To assess how much the association between migraine and depression may be explained by various measures of stress.

DESIGN

National Population Health Survey is a prospective cohort study representative of the Canadian population. Eight years of follow-up time were used in the present analyses.

SETTING

Canadian adult population ages 18-64.

PARTICIPANTS

9288 participants.

OUTCOME

Incident migraine and major depression.

RESULTS

Adjusting for sex and age, depression was predictive of incident migraine (HR: 1.62; 95% CI 1.03 to 2.53) and migraine was predictive of incident depression (HR: 1.55; 95% CI 1.15 to 2.08). However, adjusting for each assessed stressor (childhood trauma, recent marital problems, recent unemployment, recent household financial problems, work stress, chronic stress and change in social support) decreased this association, with chronic stress being a particularly strong predictor of outcomes. When adjusting for all stressors simultaneously, both associations were largely attenuated (depression-migraine HR: 1.30; 95% CI 0.80 to 2.10; migraine-depression HR: 1.19; 95% CI 0.86 to 1.66).

CONCLUSIONS

Much of the apparent association between migraine and depression may be explained by stress.

Early life course pathways of adult depression and chronic pain

Applying cumulative inequality theory, this study examines the extent to which childhood socioeconomic disadvantage and maternal depression increase the risk of major depression and chronic pain in U.S. working-aged adults. Further, I assess whether low socioeconomic status amplifies the risk of adult depression and/or pain. Using data from the 2003 National Comorbidity Survey Replication (N=4339), I find that socioeconomic disadvantage and maternal depression during youth increases the risk of adult depression and/or chronic pain. The probability of having chronic pain increases in magnitude over the life course for adults whose parents have lower educational attainment relative to those with more highly educated parents. Childhood socioeconomic circumstances are not completely explained by adulthood socioeconomic status indicators. These findings help illustrate the far-reaching influence of childhood context on adult physical and mental health.

Effect of experimental stress in 2 different pain conditions affecting the facial muscles

Chronic facial muscle pain is a common feature in both fibromyalgia (FM) and myofascial (MF) pain conditions. In this controlled study, a possible difference in the mode of deregulation of the physiological response to a stressing stimulus was explored by applying an acute mental stress to FM and MF patients and to controls. The effects of the stress test were observed on pain, sympathetic variables, and both tonic and reflex electromyographic activities of masseteric and temporal muscles. The statistical analyses were performed through a generalized linear model including mixed effects. Painful reaction to the stressor was stronger (P < .001) and longer (P = .011) in FM than in MF independently of a higher pain level at baseline. The stress-induced autonomic changes only seen in FM patients did not reach significance. The electromyographic responses to the stress test were strongest for controls and weakest for FM. The stress test had no effect on reflex activity (area under the curve [AUC]) or latency, although AUC was high in FM and latencies were low in both pain groups. It is suggested that FM is characterized by a lower ability to adapt to acute stress than MF.

PERSPECTIVE

This study showed that an acute psychosocial stress triggered several changes in 2 pain conditions including an increase in pain of larger amplitude in FM than in MF pain. Similar stress-induced changes should be explored as possible mechanisms for differentiation between dysfunctional pain conditions.

Exploring the effects of pain and stress on wound healing

Wound-related pain is complex, involving a multitude of physiological and psychological factors, such as emotional state, culture, personality, meanings, and expectations. The impact of pain on the individual can contribute to stress and compromise quality of life. The purpose of this article is to review the relationships among pain, stress, and wound healing.

How might yoga help depression? A neurobiological perspective

Depression is a prevalent mental health condition worldwide and is the leading cause of disability in adults under the age of 45. Most individuals with major depressive disorder (MDD) report only a 50% decrease in symptoms with the use of the standard allopathic treatments for depression. The mechanisms underlying depression remain poorly understood even though stress and its correlates contribute to multiple aspects of the phenomenology of depression. Thus, stress and depression are clearly linked, as stress may precipitate or exacerbate depressive symptoms and depression may be a cause and/or outcome of acute or chronic stress. Therefore, use of additional therapeutic approaches to address stress and depression, such as complementary therapies including yoga, may contribute importantly to symptom reduction. Based on an emerging picture of how stress and mood are regulated within the nervous system, and considering the Executive Homeostatic Network concept that we have recently advanced, we provide an integrative overview of biological mechanisms and substrates that may mediate depression, which should be targets for research to evaluate how the practice of yoga can mitigate depressive symptomatology.

Comparison of the cortisol awakening response in women with shoulder and neck pain and women with fibromyalgia

Shoulder and neck pain (SNP) and fibromyalgia syndrome (FMS), two musculoskeletal conditions of unknown pathogenesis, share some common features in terms of altered neuroendocrine responses, pain and stress perception. However, the pain distribution in SNP is localized, whereas in FMS is more widespread. Because regional musculoskeletal pain may represent an intermediate stage along a continuum towards widespread musculoskeletal pain we compared the cortisol awakening response (CAR) in women with SNP with the CAR in FMS patients and healthy controls (HC) in a controlled hospital-hotel setting. The aim of the study was to investigate whether SNP is related to a deviant regulation of the hypothalamic-pituitary-adrenal (HPA) axis. Eighteen women with SNP, 29 female FMS patients, and 27 female HC participated in the study. Cortisol samples were collected upon awakening, 30 and 60 min later. Questionnaires measuring pain levels, sleeping problems, perceived stress, and psychological characteristics were administered to the participants. Compared with HC, women with SNP had a tendency towards higher cortisol levels, whereas FMS had lower cortisol levels. Adjustment for potential confounders did not influence the results. Women with SNP and FMS patients reported more health complaints, pain, and perceived stress than the HC, but women with SNP were less affected than the FMS patients. Women with SNP showed a tendency towards an elevated HPA axis activity compared with HC. The current findings may indicate that the hypercortisolism in regional musculoskeletal pain represent an intermediate stage towards the development of a hypocortisolism in widespread musculoskeletal pain.

Salivary cortisol and soluble tumor necrosis factor-α receptor II responses to multiple experimental modalities of acute pain

The present study compared cortisol and soluble tumor necrosis factor-α receptor II (sTNFαRII) responses provoked by cold pressor, hot water, ischemic, and neutral water (i.e., room temperature) modalities. Oral fluid samples were collected before, immediately after, and during recovery to assess physiological responses. From baseline, the cold pressor, but not hot water or ischemic modalities, produced a significant time-dependent elevation in cortisol, whereas cortisol significantly decreased for the neutral water task. When compared to baseline, the cold pressor, hot water, and ischemic modalities were associated with decreased sTNFαRII responses over time. The sTNFαRII response to neutral water initially decreased but returned to approximate baseline levels. Pain ratings were positively associated with cortisol increase from baseline and the overall cortisol response was negatively associated with the overall sTNFαRII response.

Cannabis use in patients with fibromyalgia: effect on symptoms relief and health-related quality of life

Background

The aim of this study was to describe the patterns of cannabis use and the associated benefits reported by patients with fibromyalgia (FM) who were consumers of this drug. In addition, the quality of life of FM patients who consumed cannabis was compared with FM subjects who were not cannabis users.

Methods

Information on medicinal cannabis use was recorded on a specific questionnaire as well as perceived benefits of cannabis on a range of symptoms using standard 100-mm visual analogue scales (VAS). Cannabis users and non-users completed the Fibromyalgia Impact Questionnaire (FIQ), the Pittsburgh Sleep Quality Index (PSQI) and the Short Form 36 Health Survey (SF-36).

Results

Twenty-eight FM patients who were cannabis users and 28 non-users were included in the study. Demographics and clinical variables were similar in both groups. Cannabis users referred different duration of drug consumption; the route of administration was smoking (54%), oral (46%) and combined (43%). The amount and frequency of cannabis use were also different among patients. After 2 hours of cannabis use, VAS scores showed a statistically significant (p<0.001) reduction of pain and stiffness, enhancement of relaxation, and an increase in somnolence and feeling of well being. The mental health component summary score of the SF-36 was significantly higher (p<0.05) in cannabis users than in non-users. No significant differences were found in the other SF-36 domains, in the FIQ and the PSQI.

Conclusions

The use of cannabis was associated with beneficial effects on some FM symptoms. Further studies on the usefulness of cannabinoids in FM patients as well as cannabinoid system involvement in the pathophysiology of this condition are warranted.

Stress and tension-type headache mechanisms

Stress is widely demonstrated as a contributing factor in tension-type headache (TTH). The mechanisms underlying this remain unclear at present. Recent research indicates the importance of central pain processes in tension-type headache (TTH) pathophysiology. Concurrently, research with animals and healthy humans has begun to elucidate the relationship between stress and pain processing in the central nervous system, including central pain processes putatively dysfunctional in TTH. Combined, these two fields of research present new insights and hypotheses into possible mechanisms by which stress may contribute to TTH. To date, however, there has been no comprehensive review of this literature. The present paper provides such a review, which may be valuable in facilitating a broader understanding of the central mechanisms by which stress may contribute to TTH.